MCCS Exceptional Family Member Program Quantico, Virginia Respite Care Program “Statement of Understanding” By initialing the following statements, I indicate my understanding of the following: ____I understand that the Exceptional Family Member Program (EFMP) Respite Care Program is intended to reduce stress on sponsor families by providing temporary rest periods for family members who care for those who have special needs. ____I understand that the respite care is a reimbursement program and the established reimbursed rate may not cover costs expended by the family and therefore should be considered as a subsidy for care and not an entitlement. ____I understand, in order to be eligible for the EFMP Respite Care Program, I must have a family member enrolled in the EFMP per eligibility and enrollment criteria in Marine Corps Order 1754.4B. ____ I understand, in order to remain eligible for the EFMP Respite Care Program, my family member’s EFMP enrollment must remain current. Enrollment updates are required every 3 years or if my family member’s condition changes. If updates are not current, any costs incurred by the family during the time of ineligibility will not be reimbursed. ___I verify that my family member, who is receiving respite care, resides full-time at my current location. ____I understand, to utilize the EFMP Respite Care Program, I need to complete & return my application for approval by the EFMP manager, complete the orientation class, and sign the “Statement of Understanding”. Upon acceptance into the program, I will receive a notification letter that includes the date of application approval, level of need for each eligible family member, and my family’s hourly reimbursement rate for care. ____ I understand that the reimbursement rate is based on a formula determined by DC, M&RA using the MCB Quantico’s Child Development Center hourly drop-in rate. Each family member enrolled in the EFMP will be assigned a level of need between one and four that is determined by the documentations received by the medical screeners at HQMC EFMP during the initial or updated review for EFMP enrollment. Quantico’s EFMP Manager will determine the family’s hourly rate according to the number of family members enrolled in the program and age-typical sibling(s)/children under the age of 12 years old residing in the home. ____I understand that my EFM situation may change and can require a change in identified level. DC, M&RA (MRY-1) will make level changes when requested by Quantico’s EFMP Manger using an evidence-based process. An enrollment update or additional information may be required to approve a change in the respite level. ____ I understand that I am eligible to receive a maximum of 40 clocked respite care hours per calendar month for my family. The respite care hours will not be utilized for medical, long term care or custodial care for adults. Long term care is noted as service for more than 6 hours consecutively. _____ I understand that respite care hours will not be used to supplement, augment or substitute traditional childcare for work or attending school. ____I understand that other respite care programs funded by state and local agencies, other than the Armed Services, shall not be counted against the EFMP respite care hours. ____I understand that I will receive respite reimbursement rate at an hourly cost designed to include agetypical siblings who are not enrolled in the EFMP and who are 12 years old and under if needed. Hour counts do not vary if more than one child is supported. My child enrolled in EFMP must be utilizing respite care to include their sibling(s). ____ I understand EFM adults can use respite hours for care of age-typical children under 12 years old. ____I understand EFM adults that are eligible for level of need four respite care, may utilize direct respite care services. ____ I am responsible for interviewing, hiring, and making the direct payments to the respite care provider. I understand the providers may be a family member, friend, or professional that meets the state’s legal age guidelines for respite care providers. If my family member has a level of need of 3 or 4, I understand the provider’s age will need to be over 18 years old. ____ I understand if my family member is eligible for level of need three, I must hire a provider who is CPR trained and able to provide my family member(s) with a safe environment during respite care periods. A copy of their CPR certification with a written statement that I have trained the provider is required to be on file at the EFMP office. ____ I understand if my family member is eligible for level of need four, I must hire a licensed professional, such as but not limited to, a Registered Nurse or Licensed Practical Nurse, in order to be reimbursed at level four reimbursement rates. I must provide a copy of licensure to the EFMP office. However, if I desire, I may hire a level three qualified provider and be reimbursed at level three rates. ____I understand if the providers do not present adequate documentation of skill requirement for level three and four, they are reimbursed at the appropriate lower level for one reporting period (30 days) and may not be eligible to participate in the program after notification. ____ I understand that the respite care is typically provided in our home, at the provider’s house, or at a drop-in childcare facility and not at a public location. ____I understand that respite care reimbursement does not include the provider performing household chores other than providing meals or snacks as per parental direction. ____I understand that respite care reimbursement does not include providing transportation to or caring for a family members at activities such as practices, rehearsals, clubs and etc. _____I understand that respite care reimbursement does not include provider’s travel to my location, transportation, per diem and other personal expenses, transportation of supplies, consumable materials and equipment. ____ I understand I can obtain respite care vouchers from the Quantico EFMP office at 571-931-0524 or downloading a copy from the Quantico MCCS website at www.quantico.usmc-mccs.org/EFMP ____I will maintain the Respite Care Voucher each time care is provided. ____I will complete one voucher per care provider per month and submit the voucher(s) for reimbursement after care is provided each month. If I elect to delay reimbursement submissions for more than 60 days, I will forfeit the reimbursement. ____I understand that the respite voucher will include my contact information and the name of all my family members utilizing respite care with their EFM status, age, and level of need. I will complete the respite voucher with the date of care, military time, total hours utilized, location of care, family members cared for, total amount paid to provider, rate of established reimbursement, and total request of reimbursement to sponsor. I will adjust the respite care reimbursement rates according to family members accessing respite care services. ____ I understand if my respite care provider charges a different amount than the established respite reimbursement rate, I will submit the lower rate for reimbursement. ___ I understand that my respite care provider will sign, date, and include the provider’s title on the respite voucher to validate the hour’s utilized, family members accessing services, and rate of payment received is true and accurate. The provider will also list their phone number, which the EFMP Manager may use to randomly verify the voucher’s accuracy. ____ I or designee (w/Power of Attorney on file at EFMP office) will sign and date the respite voucher, certifying the details contained within are accurate. If I correct any misprints on the original voucher, I or designee will initial those changes. ____ I will notify the EFMP office with any changes in personal information (i.e., address, phone numbers, level 3 or 4 care provider, etc.). ____ I will fax, mail, email, or bring the completed and signed voucher to the EFMP office for processing. Quantico MCCS Finance office has 30 business days to process the voucher. ____I understand that respite care reimbursement does not impact Leave & Earning Statement or Basic Allowance for Housing and is not considered taxable income. ____I understand that during transfer to a new duty station, Quantico MCCS EFMP will pay for reimbursement until I checks into my new duty station. I understand that I will be responsible to apply for the EFMP Respite Care Program at my new location. ____I understand that if I use the respite for any purpose other than those established I will not be reimbursed. ____ I understand that MCCS EFMP is not liable for any actions or negligence conducted by any member of my family or the respite care providers I hire. By signing this Statement of Understanding, I agree to the terms listed above when seeking reimbursement through the Marine Corps Community Services Installation EFMP Respite Care Program. I also understand the USMC EFMP retains the right to verify the provision of Respite Care and legal recourse for fraudulent reporting will apply. If I am unclear as to any points described above, I will seek clarification by calling the EFMP office before seeking reimbursement. Sponsor Information: ________________________________ Sponsor/Designee Name (Print) ________________ Rank _______________________________________________ Sponsor/Designee Signature ___________________ Date _______________________________________________ Signature of EFMP representative ___________________ Date PRIVACY ACT STATEMENT In accordance with the Privacy Act of 1974 (Public Law 93-579), this notice informs you of the purpose for collection of information on this form. Please read it before completing the form. Authority: 10 U.S.C. 5013; 10 U.S.C. 5041; MCO 1754.4, Exceptional Family Member Program and E.O. 9397 (SSN). Principal Purpose: To manage services provided under the Exceptional Family Member Program. Collected information will be filed pursuant to the Privacy Act System of Records Notice M01754-6 Exceptional Family Member Program Records, which may be downloaded at http://dpclo.defense.gov/privacy/SORNs/component/usmc/M01754-6.html. Retention and Safeguards: Paper and electronic records are restricted to authorized personnel with an official need-toknow. Electronic data is maintained in a password restricted case management system and encrypted while at rest and during transmission. Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records may specifically be disclosed outside the DoD as a routine use pursuant to the DoD Blanket Routine Uses that appear at http://privacy.defense.gov/notices/blanket_uses.shtml. Disclosure: Providing information on this form is voluntary. Failure to provide the information may result in limited EFMP services.